Okay, we'll get started. Good afternoon or good evening. Welcome to the webinar on Cost-Conscious Quality Diabetes Care, a Case-Based Discussion. This webinar is hosted by the American Diabetes Association's Healthcare Delivery and Quality Improvement Interest Group. My name is Dr. Rajesh Kirk. I'm the head of diabetes at Harbor UCLA in Los Angeles, and I will be moderating this session. I'm the current chair of Healthcare Delivery and Quality Improvement Interest Group. Next slide, please. So this is our today's agenda. There will be four presentations which are titled here on this slide, and the presentations will be followed by a brief Q&A segment. Next please. Our overall learning objective today is how to provide high-quality diabetes care to our patients with diabetes without breaking the bank and at the lower cost to the patient To be more specific, we will discuss how basal insulin along with GLP-1 receptor agonist can achieve good glycemic control in many patients with type 2 diabetes without the need of intensifying therapy further to multiple insulin injections and how basal insulin alone can be enough in many patients that we treat for type 2 diabetes. We'll also discuss how generic insulins or human insulins can be effectively used to lower the cost of care for our patients when they cannot afford costly insulin analogs. And then we will discuss how to navigate the system, the healthcare system to provide lower cost quality care to our patients. And finally, we will have a discussion how our pharmacists, clinical pharmacists can help us tremendously in individualizing care and in providing lower cost quality diabetes care. Next slide, please. So just a few announcements before we start the webinar, there is a Q&A box on your screen. Please type in any questions in that Q&A box because we will be answering as many questions as possible on that Q&A box. You can also use the chat box to communicate with the panelists or to communicate with other attendees. Next please. Couple of announcements. I will encourage all of you to go on this website procommunity.diabetes.org. It's a great website for, which is a professional website for the ADA members. And it's very useful to communicate, to post your questions and have discussions on the interest group forums. Next please. ADA periodically organizes webinars, just like the one that we have today. The next one is on March 19th, listed here. And then there will be another one on April 9th. And I will encourage you, if you are interested, to register for those or pass it on to those who you think might have an interest in these topics. The ADA sends you announcements periodically about these webinars. So please do register if you have an interest in any particular topic. Next please. So for today's webinar, I have three renowned, eminent people with me today. Dr. Mayor Davidson, who is world-renowned in the field of clinical diabetes, has been on the ADA scene for almost half a century. Extremely good clinician, and most of you probably know him already. And he will be one of the speakers, Dr. Stephen Clement, who is another well-known, renowned diabetologist, and we have known him for decades. Dr. Joyce Lee, who is our pharmacist, clinical pharmacist. She runs an extremely good clinical practice, helping patients at the UCI, University of California in Irvine, in the diabetes clinic. And then myself. Next please. So I'll start off the first presentation, and that is reducing costs by individualizing treatment in type 2 diabetes. Next please. This is a case, it was a 77-year-old male, who I saw maybe five, seven years ago, who had a history of type 2 diabetes for about 20 years. Initially when he was diagnosed with diabetes, he was on oral agents, but then he suffered a stroke in 2009, and at that time he was started on basal bolus insulin, and continued on that after that. When I saw him, he was on insulin collagen, 20 units at night, and Lispro 5 units with each meal. He was also taking metformin, Victoza, which was started around 2012, and was using Freestyle Lictor 2. So he was coming to me because he had been advised to go on insulin pump by his, it was a nurse practitioner who was treating him. The glycemic control at the time was A1C 6.7%, and he was complaining of symptomatic hypoglycemia almost once a week. Other conditions, lipids, blood pressure were well controlled, and microvascular complications were minimal, just neuropathy. But the main thing was his cost, the cost of his out-of-pocket cost at that time for whatever reason was $950 per month. Next please. There are a few points I want to make on this case. The first is that this is a 77-year-old male with pre-existing vascular complications, and so glycemic targets can be relaxed. There is no reason to be as tight as 6.7%. Second, the insulin treatment can be simplified and should be simplified in a patient like this, as per the ADH standards of care. The other point I want to make is that many patients can be controlled just with CLP1 and receptor agonist, along with basal insulin, without the need to intensify treatment further to basal bolus insulin. And then given all those three points, the insulin pump and CGM may not be necessary for this patient. The CGM helps if they can afford it, but it's not something that is essential. Next please. Many of you might have seen this figure. So as per the ADH standards of clinical care, the goals for A1C depend on several factors. It depends on how long the patient has had diabetes, what is their life expectancy, but most importantly, look at the bottom panel, the lower two points. Physical needs and preferences and also resources and support. So for a patient like this, if we take into account all these factors, I will say our goal should be somewhere between 7 and 8, maybe less than 8% will be okay. So if this patient was relatively in good health, even though 77, so I've set the goal A1C at 7.5 in this particular patient, less than 7.5. Next please. There is a full chapter in the ADH standards of care, which is the treatment of diabetes in the elderly. So we know that many of our elderly patients are over-treated. It's not uncommon to have many patients being over-treated, especially those with type 2 diabetes. And it is recommended that they should be on low-risk medications, lower risk for hypoglycemia. Insulin is a high-risk medication for hypoglycemia. And if they're on complex treatment, then simplification of complex treatments is recommended to reduce the risk of hypoglycemia as well as to reduce polypharmacy. And then cost, especially in our elderly patients, it must be considered, should be one of the items always on your mind. Next please. There is a simplification algorithm that is, I will encourage all of you to take a look at this, that recommends that when your goals for A1c are relaxed, then you should try to simplify from complex insulin treatment to a more simplified treatment, which in many cases will be basal insulin alone. Next please. And so there is also something for intensification of treatment algorithm. So when you, as per the ADA standards of care, when the oral hypoglycemic agents are not adequate to get to the goal A1c, and it's time to get on to injectable therapy, these days we always will go first to GLP-1 receptor agonist, or at least that will be considered. So unless there is some reason that the patient cannot go on GLP-1 receptor agonist, then we will start basal insulin, and then slowly go over, escalate to maybe basal insulin with once daily, short-acting insulin with your biggest meal, or multiple insulin injections. But many patients, like the example that I gave, they were started on multiple insulin injections at the start. So they never got an opportunity to be tried on GLP-1 receptor agonist. So sometimes we may have to go back and re-evaluate and see whether this will be a patient who can be just on GLP-1 agonist, or a GLP-1 receptor agonist along with basal insulin. So in many cases, like my case, GLP-1 receptor agonist was added on to insulin without looking back and considering, will this patient need basal bolus insulin if he was on basal plus GLP-1 RNA? So sometimes we may have to go back and re-evaluate the injection therapy. Next please. So this recommendation is evidence-based because there are clinical trials going back as far back as 2005, this one, that showed that after oral hypoglycemic agents, when it's time to start injection therapy, if you start basal insulin or GLP-1 receptor agonist, there is an equivalent reduction in hemoglobin A1c. Of course, there will be more weight loss in the GLP-1 agonist group. Next please. And also, if the patient is on basal insulin and it's time to consider multiple insulin injections, if you add GLP-1 receptor agonist instead of adding multiple insulin injection or nutritional insulin, you can in fact get an adequate or equivalent A1c reduction. So in other words, in many patients with type 2 diabetes, a GLP-1 receptor agonist and basal insulin alone, and we have been seeing that almost 90% of patients, it may be adequate to get to goal A1c. Next please. So going back to the case, the first thing in this case, my goal was A1c less tight, not less than 7%, but I said less than 7.5% will be okay, but without hypoglycemia. The second thing was deintensifying. So instead of continuing multiple insulin injections, we kept him on basal insulin alone and added semaglutide along with metformin. And there was no need to start insulin pump. And also the CGM, he could use when he could afford, but it wasn't something essential that I will insist on because he's no more on multiple insulin injections. In my opinion, testing just once daily, the fasting or bedtime on alternate days would be enough for this patient. And so the total out-of-pocket cost just by doing all these changes was $150 per month. And then the A1c at six months was still pretty good, 7.2% acceptable. That was my case. I will pass on to Dr. Davidson, who will be giving the next presentation, Dr. Davidson. There I am. Thank you, Dr. Gard. Next, my topic is the arguments to use human insulin if necessary as an antidote to the high cost of insulin. Next slide, please. So here's my case. It's a 61-year-old undocumented person with no medical insurance. He worked in part-time construction and had a history of type 2 diabetes for about nine years. In the past, he had failed the metformin plus glimepiride plus pioglitazone triple therapy. He was then transitioned into basal insulin alone, glargine plus metformin and glimepiride, which he also failed. He was then placed on a basal bolus regimen and he was taking 42 units of glargine with 10, 12, and 16 units of aspart insulin before meals. He paid for this out of his earnings, but during the pandemic, his working hours decreased considerably and his red state governor refused to accept federal money for Obamacare premiums because as he was quoted, it was socialized medicine. Therefore, recently the patient had only been able to take his insulin sporadically. And of course, his A1C levels rose going from 7.9% before the pandemic to 9.8% just several months ago. Next slide, please. So there's really no doubt that people are rationing their use of insulin. The latest three publications I could come across were as follows, that 25% of patients on insulin underused it because of the costs. And in that study, these patients were three times more likely to have an A1C over 9% compared to those who could take their prescribed amounts. The Center for Disease Control and Prevention published statistics that said that 1 million, over 1 million patients that took insulin rationed it. And the third one was a survey, and of course that's self-selection, but in that survey, 2,000 patients who were using insulin responded and 62% said they underused insulin. 80% of them took on a credit card debt, which averaged $9,000 just to afford the $400 monthly costs. And 38% had been hospitalized for more than one day due to the insulin rationing. These were probably mostly type one patients. Next slide, please. Now here is a summary of the wholesale cost, the average wholesale price of insulins per 1,000 units. And up at the top, you have regular and NPH, rapid acting, ultra rapid acting, U500, long acting, and then two pre-mixed preparations, human insulin or analog insulins. And looking at the vial costs, just going across, you can see how high those numbers are with the exception of rapid acting insulin at $30 at the bottom. And that's because Lilly said if you had a coupon, you could get it for $30 a vial. If you look at the pen costs, again, going from left to right, you can see that they are much higher and inhaled insulin is even higher than that. So these are the average wholesale costs. And of course we know they don't reflect the actual costs, but they are a basis for how high costs of insulin are. Next slide. So this shows you how insulin prices are raised and the term that's used is shadow pricing. This is a study comparing Lantus and Levimir. And on the left, you see on the y-axis is the prices. And in May of 2001, it would cost less than $50. And looking at May of 2015, the costs went up to over $250. The striking thing is that every time one of these companies raised their prices, very soon thereafter, this other company also raised the prices to the exact same amount. Now, these are basal insulins, and you can find a similar graphs with the rapid acting insulins as well. Next slide. So all of us who use insulin, we know that there are a lot of challenges. And in using insulin, the variability is the large part of the challenges. For instance, if you give a injection of insulin, the same amount of insulin in the same site of injection in the same patient, from day to day, there is a 20 to 30% variability in how they respond to that insulin injection. Tremendous variability, of course, in the timing and the size of meals throughout the day. And recently, it's been shown that how we respond, not just the people with diabetes, but in general, how people respond to meals varies considerably. Next slide. This slide shows you that. In this study, 800 individuals were given the same meal, and a CGM was placed on them for two hours after eating. And of course, the rise in blood glucose that you see on the y-axis is a Gaussian distribution. But look at the difference between the people who had the smallest rise, that's 10% of them, their glucoses went up by 15 milligrams per deciliter per hour. And compare that to the people who had the greatest rise, the highest 10%, and you can see that that rise was 80 milligrams per deciliter per hour. So you can't use a one-size-fits-all formula for using insulin. You've got to look at each individual patient and look at their pattern of responses. Next slide. Now, there are over 25 different insulin preparations. And on this slide, in the bold, are the human insulins. And by that, I mean that the amino acids of these preparations is the same as what our pancreas produces. The other insulins are all analog insulins, where you've either changed the amino acids or you've also complexed them to different molecules in order to change the pharmacokinetics and the pharmacodynamics. Next slide. Now, anytime you hear a lecture on insulin, you'll see a slide like this. These are the pharmacokinetics and pharmacodynamics of all the general classes of insulin. It's important to note that these values are gathered by testing in normal individuals, and after only one episode, either a meal and an injection or a long-acting injection and following the patient. And short-acting insulin is what we all know, those of us who are old enough to use regular insulin, it starts in about a half an hour, peaks in two to three hours, and has a duration of four to six. The rapid-acting analogs occur, get into the bloodstream even faster at about 15 minutes, peak earlier and don't last as long, and the pharmaceutical companies are now even making faster-acting insulins. The intermediate-acting insulins are NPH insulin, and there's a lag before it starts, and then there's the basal insulins. And I'm going to show you that these differences in the pharmacokinetics and pharmacodynamics between the insulin preparations are clinically unimportant. Next slide. So let's look at just regular insulin, and those of us trained a long time ago were trained that we had to give the regular insulin 20 to 30 minutes before a meal because of the data that I showed you on the previous slide. So this is a study, a crossover study, in which people with diabetes were given regular insulin right before a meal, and the other half were given 20 minutes before a meal, and then they were checked, their blood sugars were checked for six weeks after that, seven times a day, and then they were crossed over. And you can see that the average glucose throughout the day was almost identical, and the standard deviations are very wide, showing you the variability that I talked about earlier. Next slide. In 2014, I wrote a review and looked at all the studies that compared human insulins versus analog insulins. And in the head-to-head comparisons, there were 26 studies comparing rapid-acting insulin with regular insulin with almost 10,000 patients. The hemoglobin A1C difference between those two preparations was minuscule, 0.05% difference. By the same token, looking at basal versus bedtime NPH, again, about 10,000 subjects, almost no difference in the A1Cs. In terms of hypoglycemia, there was no difference during the day, no difference in severe episodes. However, there was a small but a very significant decrease in overnight episodes with decreased hypoglycemia with basal versus bedtime NPH, but in none of these studies were bedtime snacks used, which is a very easy way to mitigate against overnight hypoglycemia. Next slide. Now, the pharmaceutical companies, in my view, have wasted a lot of time and money trying to get pharmacodynamics and pharmacokinetics of insulin that most closely mirror the insulin PD and PK in our bodies. And in three head-to-head comparisons between ASPART and faster-acting ASPART, there was no difference in the A1Cs. In the comparison between LicePro and its faster-acting compartment preparation, there was also no difference. And Alfrazo, which acts the most rapid because it's absorbed through the lungs, versus ASPART, again, no difference in A1C control. Next slide. There's even been studies in which the entire regimen has been composed of either human insulin or analog insulins. And when you compare a basal bolus regimen with analogs versus a basal bolus regimen of human insulin, and by that, I mean NPH is given at bedtime and the pre-prandial insulin is regular, in three studies, there was no difference in the A1Cs. In a study done in a hospital, they compared basal bolus with split-mixed NPH and regular insulin, and it was a short study in the hospital so they could only use blood glucoses and hypoglycemia as outputs. And again, there was no difference. Next slide. This is a rather discouraging slide, in my view. On the Y-axis are the percents of patients who took insulin, and these are the percents who would achieve certain A1Cs over 30 years, from 1988 on the left, all the way up to 2020. The blue line are the percent of patients who were able to achieve glycemic control with an A1C less than 7%. And you can see that there is no difference over 30 years in spite of all the fancy analog insulins that have been developed. The average A1C was 8.2% in 1988, and in 2018, when they got the last A1Cs, it was 8.1%. Most discouraging is the bottom curve. These are the percent of patients who had severe hyperglycemia, which was an A1C value greater than 10%. That has not changed over 30 years. Almost 20% of our patients, unfortunately, are in that category. Final slide, please. So in conclusion, the small differences in pharmacodynamics and pharmacokinetics between the analogs and human insulin are clinically insignificant. Human insulins are just as effective as analog insulins. As we all know, recent legislation passed by Congress was that patients on insulin would only have to pay $35 a month. Two aspects to that. First of all, these are only Medicare patients. The rest of the population is not covered by this legislation. And second of all, the cost is per type of insulin so that the Medicare patients would have to pay $70 a month, those on a MDI regimen. Here is the key message. Walmart charges only 25 to $30 a vial for each vial of human insulin. And as a matter of fact, no prescriptions are needed. And so the message is to bring to the attention of the providers, all of us who prescribe insulin, if our patients are rationing insulin, we should switch them to human insulin so they can afford it. And if we do that, almost all patients should be able to afford their prescribed human insulin doses. It will be NPH and regular insulin. Thank you. Well, welcome. Our group is the last speaker. We are in Washington DC DMV area, as they call it, in Northern Virginia. I'm Steve Clement. And this is our group of very, very smart PharmDs that I put together this team because we work as a team. And particularly in this combination therapy with SGLT2s and GLP1s, where it comes to getting these drugs approved by the pharmacy, we really rely on our pharmacy colleagues. Next slide. So briefly, this is my case, which I think illustrates why these drugs are in so need. This patient was a female, not prior diagnosed with diabetes, had obesity, had a syncopal event while power walking at the shopping mall. Her power walking, that was part of her therapy to keep her weight under control. Risk factors for heart disease. She had a high BMI and her father died at age 55 from complications from an MI. So clearly familial trait here. On exam, you can see her body BMI was elevated. She had a regular heart rate, eventually we found that she had not only aortic stenosis, which was the cause of her syncopal episode, but she also had a STEMI and had three vessel heart disease. So this patient clearly could benefit from drugs that can lower cardiovascular risk. Next slide. Okay, we're gonna go on. This is Brittany. Brittany's our next speaker. So on the foundation of lifestyle modifications and education, we have four main pillars. The first being glycemic management, which we all know can help decrease microvascular complications. Next we have blood pressure management, which when optimized can decrease both micro and macrovascular complications, followed by lipid management, primarily with statins being the mainstay of therapy for both primary and secondary prevention for most patients. And then that brings us to our fourth and newest pillar with agents with cardiovascular and kidney benefit, bringing us to what we're talking about here today. And more recently, in more recent years, we've actually, the importance of these agents has really been emphasized by making them potential first-line options depending on comorbidities. So taken all together, we have this multifactorial approach that we should be using in our patients to help minimize complications. Introduce yourself. Sure. Thank you, Brittany. And this is my colleague, Brittany Goode, who's a doctor of pharmacy as well. My name is Erin Adams. I'm a clinical pharmacist at Inova Health as well. And I'll be talking to you about the SGLT2 inhibitors. And as Brittany noted that they are a first line in many indications for patients with comorbid disease states. What I want you to focus on here is that not all SGLT2 inhibitors are the same. Some of them actually do have proven benefits in ASCVD risk reduction. Some have reduced heart failure events and some have CKD progression event reduction. So not all of them do. And as you notice all the way over to the right with the cost, the cost does vary but is expensive, especially for our patients who don't have insurance or for those who have Medicare, and the true out-of-pocket cost is going to greatly impact them, potentially putting them in the Medicare gap phase. So if you look at all of these options, yes, some of them are on the lower side, a $60 SGLT2 inhibitor, but it has no proven benefits in those pillars according to the ADA standards, no risk reduction in our ASCVG risk, heart failure, or CKD progression events. Next slide, please. When we look at our GLP-1RAs and our dual-GIP and GLP-1RA medications, we have a range of medications here, some that are indicated in type 2 diabetes treatment, others that are indicated in weight loss. It is really important that we actually prescribe for the correct indication associated with that. Here, of course, you can see that some of them are weekly injection, daily injection, twice daily injection, and we do have an oral GLP-1RA. However, that particular one does not have cardiovascular risk reduction. So ribelsis, although semaglutide is the active ingredient, does not have that cardiovascular risk reduction, while the injectable semaglutide, ozempic, does. There actually is an update to this slide. So Dr. Clement did point out to us that the Wagovi semaglutide, that's the one for weight loss, actually does now have a new indication for lowering MACE outcomes or helping with MACE outcomes, and especially those who have a prior cardiovascular event. So in that case, then, we have a new update there. But I'm going to focus on our ADA medications here. So in terms of our GLP-1RAs and dual-GIP GLP-1RAs, they can be first-line for our patients, but look at that cost. We're looking at an average cost of $900 to $1,000 per month, and we've seen them higher, up to $1,500 in this area per month. And so for those patients, again, who don't have insurance or Medicare patients, this is definitely going to get them into that gap phase easily. So the coverage can be great, but not all of them also here have relative or the risk reduction associated with cardiovascular risk reduction. So we really want to make sure that we're focusing on the medications that do have that cardiovascular risk reduction. So in terms of type 2 diabetes, we're looking at our injectable semaglutide, Ozempic is the brand name there, dulaglutide, which is trulicity, or liraglutide, which is Victoza. Those do actually have, in terms of type 2 diabetes, the cardiovascular risk reduction. But again, when it comes to that cost, not everybody can afford that. And that's where I'm going to introduce my colleague, Tong Tran, who's going to talk about those barriers. Thank you, Erin. So this is one of my favorite things to talk about because this is what I do at Inova, is I focus on medication access for our patients. We practice the art of medicine. We go through these guidelines. We choose high quality plans to improve our patient's outcomes, but we still have to deal with access to those medications. So I'm going to go over some tips that I've come up with over the years. Hopefully it will help you in your practice. And the first is, since most of our patients have a third party insurance, it's the coverage review process and understanding the prior authorization process to these medications. Payers do not practice the art of medicine. They focus on the science. And what I mean by that is, they will only cover medications that base off of their official FDA indication, especially these high cost medications. So going back to what Erin had mentioned before, there's different products with different indications. It does need to match the FDA approved indication for payers to cover it. And these are $1,000 medications, $600, $700 medications. So they are pretty expensive. I put detailed charting in there because if you guys are like the providers I work with, they don't often do their own prior authorization and it's their staff. And most of the staff are just pulling directly from the chart. So if you have a pre-diabetic patient who is now diabetic and they need to start a GLP-1 and you forget to update their diagnosis, that could hamper the access for the patient. Now, even if they have coverage, we still have patients who have high cost sharing plans, Medicare, high deductible plans, marketplace plans. So we have some tips for that. There are manufactured coupons, which what most providers think about. Just a limitation on this, it's only for commercially insured patients and there's max caps. And usually they're between $150, $200 maximum caps. And if you think back to those costs previously, it makes a small dent in that cost. Then we have patient assistance programs. These are directly from the manufacturers. These are great for your patients who are in that low income, but they don't quite qualify for Medicaid and state assistance. They're in that 200 to 400% of FPL. There's programs from the manufacturers that if they meet the income requirements, they can get the medications at no cost, including community programs. Those are a little bit tougher to get by because diabetes is such a big disease state that there's not that much funding for community programs. But those manufacturer programs are a great resource. Those are all under a website called needymeds.org. That's what I usually focus on. And then those GoodRx, SingleCare, Mark Cuban's Pharmacy, they have discounted medications. And despite what the commercials say, the 70%, 80% discounts, those aren't really true discounts. Keep in mind, those are discounted based off of the average wholesale price, which is a number no one really understands how we came up with that number. But those are not the true costs. Those prices that we showed in the previous slides, those are based off of the GoodRx and SingleCare prices. So that's what the patients would be paying if they didn't have coverage and they were using those coupons. And lastly, resources within your own healthcare system. Within Inova, we have the department I work in, which is medication access. So hopefully your department or health system has something similar and you can always leverage that. Now, the last part of this is shortage. If you notice, it's blank. So I want everyone to close their eyes and use your imagination because that's how you solve the shortage problems. You have to be creative. There is no simple solution for this. One thing to keep in mind is what Aaron had mentioned earlier. Not all SGLT2s are created equal. Not all GLP-1s are created equal. Not all insulins are created equal. So be creative. Try to get a similar indication because if we look at just A1c control, those SGLT2s, they don't have a lot of, it's less than 1%. So unless we're going to get that additional benefit for cardiovascular benefits, CKD, heart failure, there's other medications that are cheaper for strictly A1c control. So we want to try to use our imagination, be creative, do the best we can with what we have at the time, and then circle back maybe in three months, six months to see if the shortage has resolved. Thank you. Next slide. So again, thank you for all of you. That was phenomenal. And this is obviously a work in progress. So maybe next year we can do this webinar again and update all these things because they are rapidly changing. So what about the patient that I told you about? Well, she was my patient in the hospital. We used IV insulin, transitioned to Glargine and Premio Lispro, and we got her home on EMPA right away. And we've been set up to 25 milligrams a day. I'm pretty sure she's on a GLP-1 agonist at this point. It's been about six months I've seen her. I do inpatient part. I had to hand her off. But she is clearly a patient that could greatly benefit from this class of drugs on reducing cardiovascular events. And that's the end of my section. Thank you very much. Okay, great. Hi, everyone. My name is Joyce Lee. I'm a clinical pharmacist, and I'm also a faculty member with University of California at Irvine. Next slide, please. So before I start talking about my part of the, my sections of the talk, I'd like to just provide you with a quick recap on some of the approaches that we have already covered so far. So, so far we have discussed about different cost-conscious approaches to diabetes care. For example, Dr. Gard talked about individualized diabetes management through regimen simplifications. And Dr. Davidson talked about evidence-based selections of insulin types to cut costs. And finally, Dr. Clement and his team of pharmacists talked about using GLP-1 receptor agonists and SGLT2 inhibitors as part of a comprehensive diabetes management to achieve cost-effective care through cardiovascular risk reduction. Next slide, please. So in my part of presentations, I would like to talk about implementing chronic care model as a cost-conscious approach to reduce costs to our healthcare system, as well as to the patients. Next slide, please. So the ADA standards of care in diabetes talked about chronic care model in length, and you can find these discussions about chronic care model under the first sections or the first part of the ADA standards, and it's titled Improving Care and Promoting Health Populations. So evidence tells us that chronic care model, especially in the primary care setting for people with type 2 diabetes, can contribute to 56.6% reductions in cardiovascular disease risks, and 11.9% reductions in microvascular complications, and a 66.1% reduction in mortality. And perhaps what's most relevant fact for this particular presentation is that the chronic care model can contribute to more than $7,000 of healthcare savings per individual over a five-year period, and this large amount of cost savings was really due to the fact that patients under the care of a chronic care model had fewer diabetes-related complications and all costs of mortality compared to the non-chronic care model approach. Next slide, please. Okay, so what makes ADA an advocate for the chronic care model? One main aspect is that chronic care model takes a form of care delivery that is collaborative in nature, and it consists of interprofessional team members including nurses, dieticians, clinical pharmacists, and other healthcare professionals. Next slide, please. So to put things in context, I would like to provide you with an example of a chronic care model from where I practice. So in addition to my faculty appointment at UC Irvine School of Pharmacy and Pharmacy School of Sciences, I also provide service at the UC Irvine Health Family Health Center, which is the oldest federally qualified health center, in short, FQHC, located in Orange County, California. So the FQHC, where I practice, sees about 25,000 medically underserved patients every year, and of which about 99% of the population live below 200% of the federal poverty level, and 11% are uninsured. So during the height of the COVID-19 pandemic, and together with some of my family physician colleagues and nursing practitioner colleagues, we started a referral-based pharmacy-led comprehensive medication management service. It's operated under the use of collaborative prescribing agreement, which allow clinical pharmacists the privileges to adjust medications when needed. So the service is also called Care Pills, where each letter stands for a type of challenge or need that the clinical pharmacist will be able to help with. So as you can see, C stands for closer monitoring, A for adherence challenge, R for resistance to drug therapy, E for empowerment in patient-owned therapy, P for polypharmacy, I for initiation, titration, modification of medications, and L for lack of drug or device knowledge or lack of drug administrations or device techniques, and S for switching of medications. Next slide, please. So Care Pills is really integrated in the day-to-day practice, and I work collaboratively with the interprofessional team by providing care in between provider visits in the form of telemedicine visits, as well as in-person visits. So for example, in the case of medication simplifications discussed by Dr. Gar earlier, the patients can be referred to Care Pills to streamline the regimen, and along with closer monitoring and education, and in terms of switching from insulin analogs to human insulin to cut costs as discussed by Dr. Davidson, Care Pills can help with the switching process and the follow-up to ensure a smooth transition. And similarly, in the case of Dr. Clement's patients, Care Pills will be able to empower patients on their drug knowledge, letting them know that GLP-1 receptor agonists and SGLT2 inhibitors are not just for their sugar, but also for the protections of their heart. Okay, next slide, please. So last year, together with some of my family physician colleagues and nurse practitioner colleagues, we had the privilege to present the impact of our chronic care model on A1c among medically underserved patients with diabetes in primary care at the ADA's 83rd Scientific Sessions in San Diego. So the study was a retrospective quality assurance study of 104 patients with the aim to evaluate the first impact of A1c reduction at three months after incorporating chronic care model on patients with different baseline A1c levels. So the results of the study was largely positive, with meaningful A1c improvements achieved at three months. And this is especially important in our practice setting in FQHC, because chronic diseases are generally harder to achieve control when the patients have numerous social determinants of health. Next slide, please. So the benefits of chronic care model, including interprofessional approach to diabetes care, is really well documented, and this is worldwide. And specifically, incorporating clinical pharmacists in the care team has shown to improve clinical outcomes, and these outcomes include A1c values, blood pressure readings, lipid profile, ACVD risk factors, and it has also shown to improve humanistic outcomes, which include quality of life, diabetes-related distress, and patient satisfactions. And incorporating chronic care model has also shown to improve economic outcomes, both direct and indirect costs. So beyond the positive impact of chronic care model on this triple aim that I have just talked about, there's a randomized control trial of 411 patients, which I had the pleasure to lead more than like seven years ago, also showed that pharmacists involved collaborative care reduced provider workload by 2.5 times compared to the usual care. And this allowed the providers to have more time to focus on other patients who may be more acutely sick or require in-depth physical examination. Next slide, please. So this is just a summary of the four cost-conscious quality diabetes care approaches that we have covered so far. And next slide, please. So that's the end of my section. Thank you for your attention, and Dr. Garg, back to you. All right. Thank you, panel, for exciting talks. Extremely useful. So we'll open this for question answers now. I don't see any questions in the Q&A box. So if anyone has a question, please type or ask. The audience, I think, can unmute and ask a question. Kelly, just type. I have a question. I'm not sure if you can unmute and ask. If not, you can just type, and I will read it out. OK. So you cannot unmute. So please type your question. She's typing, so we'll wait. We'll wait for your question, Kelly, if you have time. In the meantime, anyone from the panel wants to raise anything, additional issues? Well, Josh, if we have just one quick second, one thing I was impressed on when we put together a discussion group, and this is from all of us, is the idea that filling out those pre-authorization forms is not something you want to do as an amateur. You want to have experience with this, because if one little answer is wrong, it not only may reject the medicine, but it may reject it for a year or even longer. So I would just advise, please never do that. If you're an amateur, you've never done them before, you don't have experience in it, please refer to your colleagues in your institution to help you with that, because there's a lot that can go wrong on those PA forms. Yeah, I agree. I think we do have a tendency not to utilize our pharmacy colleagues as much as we should, so it can really help our patients to involve clinical pharmacists in not only in how to get the medications covered, but also in terms of individualizing. They may suggest an alternative. I don't see any other questions in the Q&A session. There was one question in the chat box, which I think is for Dr. Davidson. This is my chat question, and I just noticed one for Joyce in chat. Oh, you did? Do you want me to answer that question? Yeah, please. Okay, so the question is, is the chronic care model being used in other settings? And the answer is yes. So it actually is used in different types of forms and different designs, and so it doesn't need to be in one fixed format. So the most important thing is what is important for your care team to create one. So you don't need to follow strictly one formula. You can be creative. And as long as your team feel comfortable with it, I think that's really the best way to establish a successful chronic care model. But yes, yes, there are other places with chronic care model that's being used in other settings and other conditions as well, not just diabetes. So if I understand the question from Kelly Close, what are the questions that you all would like to hear from people with diabetes for their pharmacists? If I understand this question, it's whether the patient should be talking to their pharmacist. That's not what we are suggesting here. What we are saying is the providers, the diabetes care providers, they should involve pharmacists in clinical decision-making when they encounter the cost issue or the affordability or even compliance issue, adherence to medications. So it's not that we are asking patients to talk to their pharmacist for advice, but it's the diabetes care providers. They should involve pharmacists through most of the health systems have EMRs. They can send messages through EMR or they can pick up the phone and talk to them and see how they could help in a particular case. Or if in some systems like in Steve's case, I think the clinical pharmacists are embedded in the clinic and part of the team. So that's a tremendous improvement on what we do. But Jess, we can clarify that. Erin? And when you have a clinical pharmacist on your team, we can have those collaborative practice agreements. And again, as Joyce mentioned before, we can help to decrease your workload, especially for those patients that really do need some one-on-one help in that case. If you've never worked with a clinical pharmacist, really most, I should say, majority of clinical practice pharmacists are PharmD and have board certification. So it's not just state licensure, but it's also a board certification that we've achieved. We've had lots of experience with various medications and therapeutics. And so we really do have that impact of calling patients or seeing them one-on-one to help them and really spend the time that they need to understand their disease state and especially their medications. If you're interested in having a clinical pharmacist work with you, the easiest thing to do is actually contact your local school of pharmacy in the state. Most schools of pharmacy are looking for their faculty to be in clinical practice. And sometimes you can get them for free as long as they can have students at the practice site learning from them. So you get a really good benefit of having a clinical pharmacist on staff with you, technically in some cases for free, and they can really give you some advantages in that case. That's wonderful. The way I understand it, it's just like we collaborate with social workers, involving them in a particular case. They also help us. One minute left for any last minute comments. Please go ahead, Steve. Yeah, well, they also help us because they're looking over our shoulder if we make a mistake, which is great because, you know, we get tired and we get busy and they're like our guardian angels. All right. Thank you so much, all. You're right on the clock. Thank you, Karina, for helping in the background and Annie and the whole ADA team for making this webinar possible.

webinar

cost-conscious

quality diabetes care

case-based discussion

American Diabetes Association

individualized treatment approaches

human insulin

SGLT2 inhibitors

GLP-1 receptor agonists